0HARMACY OB/GYN 0HARMACY

Transcription

1 2 E River Road, Suite Tucson, AZ (fax) PATIENT DETAILS Today s Date Full Name Age Sex Social Security # Date of Birth Birth Order CONTACT INFO Address of Primary Insured Address Line 2 City Postal / Zip Code State Country We will send an confirmation for scheduled appointments. Mobile Phone Home Phone Work Phone Primary Physician Phone Number OB/GYN Phone Number

2 REFERRED BY Name EMERGENCY CONTACT Name Relationship Mobile Phone Home Phone INSURANCE Name of Primary Insured Relationship to Insured Date of Birth of Primary Insured Name of Insurance Carrier Member ID # Group ID # Address from the back of your insurance card HEALTH HISTORY What brings you to Tula Wellness? What concerns about your health do you have? What are your health goals? MEDICAL CONDITIONS Please list the name and diagnosis date of any current medical conditions. Please list the name and diagnosis date of any previous or childhood medical conditions.

3 DIAGNOSTIC STUDIES Have you ever had diagnostic studies? Last Date Done & Results (-/+) Colonoscopy Bone Density Electrocardiogram Other SURGERIES & HOSPITALIZATIONS Family Health History Please tell us about your family. Please include any family member with a history of tuberculosis, diabetes, cancer, emphysema, kidney disease, ulcer, nervous breakdown or gall bladder disease. Mother Health Status Age if Alive/Age at Death Cause of Death Health Problem Father Health Status Age if Alive/Age at Death Cause of Death Health Problem Other family Health Status Age if Alive/Age at Death Cause of Death Health Problem Additional information related to your Family Medical History you would like us to know:

4 SOCIAL AND SOCIOECONOMIC HISTORY Occupation Employer Highest Degree Earned Do you enjoy your job? Why? / Why not? Present Marital Status Spouse / Partner s Name # in Household, including children What are your main interests and hobbies? HABITS & LIFESTYLE Do you eat breakfast? YES NO Do you eat three meals a day? YES NO Do you feel rested upon awakening? YES NO Do you spend time outside? YES NO Do you take vacation? YES NO Average hours per night of sleep Average hours per day of television What do you do to relax/recreate/socialize/cope with stress? What are the major stressors in your life? When are you happiest? What gives you joy?

5 Alcohol Use If yes, what kind? If yes, how many per week? Tobacco Use If yes, how many packs? If yes, are you interested in quitting? Recreational Drug Use If yes, what kind? If yes, how many per week? Have you ever felt that you ought to cut down on your drinking or drug use? Do you get annoyed at criticism of your drinking or drug use? Do you ever feel guilty about your drinking or drug use? Do you ever drink for an early morning "eye opener"? Do you feel safe in your surroundings? Do you have a history of sexual abuse? Describe your energy level throughout a typical day rating on a scale of 1-10: 1=Extreme Fatigue/10=Feeling Great and Energized Early Morning Mid Morning to Noon Mid Afternoon Evening Please describe any associated food or drink cravings (sugar, coffee, cola, etc.): Have you seen a practitioner of alternative medicine? Acupuncture Neuro-Linguistic Programming Hypnosis Fasting Orthomolecular Biofeedback Traditional Chinese Medicine Yoga Chelation Therapy Aromatherapy Nutritional Medicine Light Therapy Meditation Herbal Medicine Homeopathy Environmental Medicine Ayurvedic Medicine Guided Imagery Bodywork Naturopathic Medicine Other

6 WOMEN S HEALTH HISTORY Date of last menstrual period Number of children Children s ages Age at start of periods Age at end of periods/menopause Menses Irregular Painful Other History of abnormal pap smears? If yes, please explain follow-up and treatment you received. History of breast surgery If yes, please explain follow-up and treatment you received. Date of last mammogram Results of mammogram Date of last pap smear Results of pap smear SEXUAL ACTIVITY Sexual Orientation Are you sexually active? Birth control method Do you practice safe sex? ALLERGIES Do you have an ALLERGY to a drug or other substance? If yes, please describe.

7 CURRENT PRESCRTION MEDICATIONS Drug Name Strength Dosage SUPPLEMENTS AND OVER-THE-COUNTER Drug Name Strength Dosage IMMUNIZATIONS Measles/Mumps/Rubella Polio Tetanus & Diptheria Chicken Pox Pneumovax Tetanus-Booster DPT Influenza Hepatitis A Series 1 Series 2 Hepatitis B Series 1 Series 2 N/A ANTIBIOTICS How often have you taken antibiotics? Infant / Childhood Teen Adult Have often have you taken oral steroids? Infant / Childhood Teen Adult TOXIC METALS Have you ever been exposed to toxic metals in your job or home? Do you have dental amalgams (silver fillings) or root canals?

8 EMOTIONAL WELL BEING How well have things been going for you at school? How well have things been going with close friends? How well have things been going for with your children? How well have things been going for you at your job? How well have things been going for you with sex? How well have things been going for you with your parents? How well have things been going for you with your social life? How well have things been going for your attitude? How well have things been going for you with your spouse/partner? NUTRITION EVALUATION Please list all foods and drinks you have consumed in the past 24 hours. Include meals, snacks, beverages and condiments. Food Items; How Prepared (Baked, Fried, etc.); Amount (Cups, Tablespoons, Ounces, etc.): Is this a typical day? How many servings of fruit do you eat/drink each day? Serving = 1 small piece of fruit, 1 cup canned or chopped fruit, 1 cup dried fruit. Are you currently on a special diet? If yes, please describe: Do you eat red meat? What kind? How many times per week? Do you have symptoms immediately after eating such as belching, bloating, sneezing, hives, etc.? If yes, are these symptoms associated with any particular food or supplements? Please name the food or supplement and the symptom(s); i.e. Milk = gas,diarrhea Do you feel you have delayed symptoms after eating certain foods? (symptoms may not be evident for 24 hours or more) such as fatigue, muscle aches, sinus congestion, etc.) Does skipping a meal greatly affect your symptoms?

9 Have you ever had a food that you craved or really binged on over a period of time? (Food craving might be an indicator that you are allergic to that food) If yes, what food? Do you have an aversion to certain foods? If yes, what foods? REVIEW OF SYSTEMS Please check any current symptoms you may have: Constitutional Recent Fever Night Sweats Hot Flashes Cardiovascular Chest Pain/Discomfort Palpitations Short of Breath with Exertion Unexplained Weight Loss/Gain Decline in Libido Respiratory Cough/Wheeze Coughing up Blood Genitourinary Painful/Bloody Urination Leaking Urine Nighttime Urination Unusual Vaginal Bleeding Concern with Sexual Function Skin Gastrointestinal Rash New or Change in Mole Thin, Ridged or Splitting Nails Heartburn/Reflux Blood or Change in Bowel Movement Nausea/Vomitting/Diahhrea Pain in Abdomen Irritable Bowel Syndrome/Digestive Problems

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11 HEAD Headaches Faintness Dizziness Insomnia DIGESTIVE Nausea/Vomiting/Diarrhea Constipation Bloated Feeling Belching/Passing Gas Heartburn Intestinal/Stomach Pain EYES Watery/Itchy Eyes Swollen, Reddened Bags or Dark Circles Blurred or Tunnel or Sticky Eyelids Vision not near- or farsightedness EARS Itchy Ears Ear Aches or Infections Drainage from Ear Ringing/Hearing Loss WEIGHT Bing Eating/Drinking Craving Certain Foods Compulsive Eating Water Retention Underweight ENERGY/ACTIVITY Fatigue/Sluggishness Apathy/Lethargy Hyperactivity Restlessness

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13 OTHER Frequent Illness Frequent or Urgent Urination Genital Itch or Discharge GRAND TOTAL Signature Date